December 13, 2010

The last government had a peculiarly Stalinist approach to public wellbeing. It created over 1200 new laws, a record number for any government, many of which reflect a naïve belief that these would change public behaviour. Some were clearly stupid; thinking that drinkers would be deterred from behaving badly when drunk for fear of legal sanctions misses the point that many people get drunk deliberately to lose the inhibitions that such sanctions bring!

Perhaps the most pernicious principle of law was the one declared in 2005 by way of a decision of the Court of Appeal (Criminal Division) which did not, prior to the hearing, make it into the public arena for discussion, nor was the reasoning the product of debates in Parliament. The effect of this decision is to deny the defence of necessity to those growing or possessing cannabis to treat medical conditions for which other treatments were ineffective. In the words of the Court, “its role [of the defence] cannot be to legitimise conduct contrary to the clear legislative policy and scheme”. The consequence was that ill people for whom cannabis might be the sole means to relieve suffering are no longer able to plead that this was the reason they had the drug if they get arrested.

Surprisingly many do get arrested sometimes in very aggressive ways. Just last week I received an email detailing how a middle aged ex teacher with multiple sclerosis has had her front door broken down by the police in dawn raids on three occasions over the last six years to combat her use of cannabis for medicinal purposes. I presume everyone, except perhaps the police involved, would agree this is inhumane, a travesty of justice, and a complete waste of public money. There are regular court cases in which this defence is denied and so individuals are obliged to plead guilty to possession of what is now a Class B drug which carries a sentence of up to 5 years’ in prison, or up to 14 years if the court decides intent to supply (dealing) was present. Such judgments are devastating to the patient and their families but also quite distasteful to those charged with enacting the penalties. I have spoken with many magistrates and a significant proportion express privately their extreme dislike of being forced to criminalise such users of cannabis.

Why did the Court of Appeal do this? Since the reclassification of cannabis to class B in 2009 the UK has some of the most punitive laws on cannabis in Europe. Until 1971 cannabis was legal in the UK if in medicinal form and had been so for centuries. It was greatly beloved of Queen Victoria who swore by its analgesic properties claiming that she would never have had so many children without the help of this medication. The medical license was removed in 1971 because a couple of rogue GPs in London, who were campaigning to make cannabis legal, began to prescribe medicinal cannabis with the recommendation that it be added to tobacco and smoked. Whether the threat to UK society of this behaviour was sufficient to ban a whole class of medication is very questionable, but since then we have had no cannabis medicines in the UK. This puts us in clear contrast to many other European countries where it is available on prescription [1]. Even in the USA, which has even more extreme laws for recreational cannabis use than the UK, many states make cannabis available for health reasons on a doctor’s recommendation.

Until 2005, users arrested for cannabis possession did invoke the defence of medicinal necessity (encompassed in the concept of Duress of Circumstance) which was that they needed cannabis as no other medication worked for their condition. So why did the Court of Appeal ban it in 2005? Reading the legal arguments the same circular attitudes that permeated the Labour government’s whole biased and ignorant attitude to drugs are recapitulated [2]. The decision is logical if we make two flawed assumptions, that cannabis is illegal because it is harmful to society, and that punishment is an acceptable and effective deterrent. This translates to illogical conclusion that ill people with conditions such as multiple sclerosis, chronic pain and spasticity need to be protected from the potential harms of cannabis by criminalising them! As was noted following the decision the Court was influenced by the government’s refusal to relax the legislation in this context despite recommendations to do so by the House of Lords Select Committee.

Another reason was that the defence was becoming too common and that there would be obvious risks for the integrity and the prospects of any coherent enforcement of the legislative schedime. No concern for patient suffering there then, just some difficulties for the enforcers. Nowhere in the judgements is there any discussion of the historical precedents that cannabis was a useful medicine and that the decision to make it illegal was based on legal and moral rather than medical grounds. Perhaps not surprising given that the UK is one of the few western countries where drug control is vested in the ministry for justice/law rather than health. Nowhere is there any scope for allowing a doctor to decide if cannabis might be useful. The intention of the decision is clear – reduce cannabis use for whatever reason – by punitive means.

Is this just? Of course not, the judgment reflects the nastiness of a statutory scheme that makes no provision for the medicinal use of cannabis, and existing law reflects a blinkered and regimented view of life and behaviour. The consequences of this distasteful state of affairs is that it not only denies medical help to a profoundly suffering group of disabled people but also adds huge mental distress from the legal process and the public embarrassment of court exposure to a group of otherwise law-abiding citizens. Even worse some have had their possessions and bank accounts seized under the new proceeds of crime legislation where there is evidence that the offender has “benefited” from his “criminal conduct” (expressions that have a legal meaning but the confiscation laws are draconian). This situation surely would not continue if the public were aware of the iniquity of the law. Some patient test cases are now under review in the European Court and so hopefully it will soon be overturned.

The recent release of the cannabis extract spray medicine Sativex has been a move in the right direction but it will not deal with the needs of all patients and most doctors are still not willing to prescribe it. Some patients have used the right of freedom of trade in Europe embodied by the Schengen agreement to obtain medicinal cannabis from European countries such as the Netherlands where it is a prescription medicine [3]. There is some uncertainty about the legality of this approach – the Home Office recently released a statement denying the legality of this approach in contrast to letters previously sent to individuals that sought clarification on the matter. It would be much preferred by patients, carers and doctors alike for justice to be enacted by revoking the current law. The new coalition government has asked for the public to suggest laws to be revoked – this is one I and surely any sane and humane citizen would recommend repealing.

Comments in italics are taken from the report by Stephen Leake, Barrister R. v Quayle and Other Appeals; Attorney-General’s Reference (No.2 of 2004), Re Ditchfield

December 9, 2010

Drug harms in the UK: A multi-criteria decision analysis

The ISCD’s first published work, launched in the Lancet on 1 November 2010, has attracted considerable attention in the media worldwide and from the public. The summary below lays out the basics of what the papers shows and what it cannot. To read the paper in full, download it for free from the Lancet’s website.

Overview of paper
An assessment of the various harms of drugs used recreationally in the UK using multi-criteria decision analysis (MCDA) – a method that uses relevant experts’ knowledge and experience to assess the actual and relative harms.

What is its purpose?
To assess drugs in terms of their known harms to individuals, those around them and more broadly, to domestic and international society. Showing drugs’ harms relative to each other also enables more objective and informed assessment of their harms individually and in relation to their current controls.

What does it show?
The report found heroin, crack cocaine, and methyamphetamine to be the most harmful drugs to individuals (part scores 34, 37, and 32, respectively), with alcohol, heroin, and crack cocaine as the most harmful to others (46, 21, and 17, respectively). Overall, alcohol was the most harmful drug (overall harm score 72), with heroin (55) and crack cocaine (54) in second and third places.
It also found the legal status of most drugs to bear little relation to their harms.

What does it not show?
Because of the many factors that could change, the report does not take the legal status of a drug into account. This will clearly have some impact on its level of harms, for instance alcohol’s regulated availability means that many more people have access to it than most drugs, which will have an effect on its level of harm. Similarly, the controlled status of some drugs will make them more harmful as unsafe production of the drug introduces contaminants and risky practices by users puts them at risk of diseases such as Hepatitis C and HIV.

The rankings of harm to the user would be unlikely to change drastically if all drugs were controlled or, conversely, not controlled, as those harms are intrinsically linked to their effects on the mind and body. However, the harms to society could change if a drug’s legal status changed. There are examples in a number of countries of different levels of control, such as in Brazil, Mexico, Portugal, Spain, the Netherlands, Finland and parts of Australia and the USA, amongst others. However, it is not possible to expect identical results if replicated in the UK, given the wide variety of cultural and historical factors that can influence drug use and especially problem drug use.

Areas of development
This paper represents a step forward in our understanding of drug harms but is by no means the definitive answer. Repetition of the MCDA process with other relevant groups (such as police, teachers, doctors, politicians, users) and in other countries would help to build a fuller picture of the range of harms. Taking into account the various benefits of drugs would also enable better understanding of why people take drugs and how they might positively impact on users and society.

December 3, 2010

Today’s EU-wide ban on mephedrone based on recommendation from Europol and EMCDDA is remarkable for its lack of scientific evidence. The Europol/EMCDDA report primarily relies on user experiences and a handful of hospital admissions, with no formal studies to demonstrate the actual or potential harms of the drug and with mephedrone only formally cited in one case as the cause of death.

It is not yet possible to say how harmful mephedrone is given the lack of evidence. However, by legislating on a substance without reliable, scientifically-based evidence, we run the risk of causing more harm through criminalising users than might be caused by the drug itself. The evidence on drug harms should not be sacrificed for political and media pressure, especially given recent research by Sheila Bird positing that a drop in cocaine deaths in 2009 was due to users switching to mephedrone.

A minimum data set, specifying what needs to be known about a substance in order to deal with it effectively, through legislation or otherwise, is urgently needed, at both the domestic and international level. The Independent Scientific Committee on Drugs (ISCD) have been developing a minimum data set for this purpose. You can find it here or at http://www.drugscience.org.uk/minimumdataset.html.